Gilmer Independent School District

University Student and ACP Application / Request

Observation Procedures and Guidelines

Observation Guidelines

1. All cell phone use for any purpose during observations is prohibited.
2. Professional dress is required for all observers.
3. Provide the campus with your driver’s license when you arrive on campus to receive a visitor’s badge.
4. You may only observe on the campuses provided to you by the assistant superintendent.
5. Remember that all information concerning students is confidential.
6. The campus administrator has the authority to deny or discontinue requests for observations.
7. Respect the campus making decisions of which classrooms and teachers you will be assigned to observe.
8. You will be notified of your assignment via email from Dr. Dawn Harris. It is the student’s responsibility to contact the assigned cooperating teacher to schedule time(s) that best fits his/her instructional schedule.

My electronic signature indicates that I have read the procedures and instructions for Gilmer ISD observations. I understand and will comply with these guidelines. I understand that it is not a requirement of Gilmer ISD to allow me to observe on any campus. I will provide all the requested documentation and information before I am given further direction on the process of observing on the campuses. I will respect the confidentiality of the students, teachers, and campus during my time of observation.

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CRIMINAL HISTORY RECORDS FORM

CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK

The Gilmer Independent School District is required by state law to obtain criminal history record information of all applicants for employment, independent contractors, student observers, and volunteers with the district (Texas Education Code Chapter 22, Subchapter C).

The Gilmer Independent School District is an equal opportunity employer that maintains a policy of nondiscrimination with respect to all employees and applicants for employment. All personnel actions, such as recruitment, hiring, training, promotion, transfer, compensation and benefits, discipline and termination are administered without regard to race, sex, color, religion, national origin, age or disability of otherwise qualified individuals.

The information will be used solely for the purpose of assisting GISD in conducting a criminal history check (local, state and national). The information below, i.e. race, sex and birth date will not be used for employment purposes, but is required for identification purposes for the criminal records check. A report showing a record of conviction will not automatically eliminate you from employment consideration or offer of contract, but it may do so. The district will consider the nature of the offense, the date of the offense and the relationship between the offense and the position for which you are applying.

Please complete the following:

I certify that the information contained in this application is true, correct, and complete. I understand that any misstatement, omission, falsification, or misrepresentation of fact in this application may disqualify me from consideration for employment or, if I am hired, may result in disciplinary action up to and including termination.

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OBSERVER INFORMATION

Legal Name
* First	Middle	* Last
Maiden and/or Other Name Previously Used
* Date of Birth	* Gender	* Ethnicity
(ex. 01/01/1965)	Male Female	Asian African-American Hispanic Caucasian Other
* Social Security Number
(ex. ###-##-####)
* Drivers License or State ID Num		* State Issued
		Select a State... Texas Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Other states in which you have been licensed to drive
ADDRESS INFORMATION
* Address		Apt Number
* City	* State	* Zip Code
	Select a State... Texas Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming	(ex. 77024 or 77024-2803)
* Home Phone	Alt. Phone	* Email Address
(ex. 713-464-1511)	(ex. 713-464-1511)
EMERGENCY CONTACT INFORMATION
* Name	* Phone Number
	(ex. 713-464-1511)
ACP/UNIVERSITY INFORMATION
* ACP/University	* Certification Area	* Observation Hours Required
		1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 50+
Please select the level you are interested in.
Elementary	Middle School	High School
Subject(s)

CRIMINAL HISTORY INFORMATION
1. Have you ever been charged or arrested for any felony, class A or class B misdemeanor? YES NO
If yes, please specify
Date	Place
(ex. 01/01/1965)
Name & Level of Offense
Explanation
2. Have you ever plead guilty or nolo contender to any criminal offense (excluding minor traffic offenses)? YES NO
If yes, please specify
Date	Place
(ex. 01/01/1965)
Name & Level of Offense
Explanation
3. Have you ever been placed on probation, received deferred adjudication, pretrial diversion, intervention, suspended sentence, community supervision, probation without adjudication of guilt? YES NO
If yes, please specify
Date	Place
(ex. 01/01/1965)
Name & Level of Offense
Explanation
4. Have you ever been convicted of any offense (excluding minor traffic offenses)? YES NO
If yes, please specify
Date	Place
(ex. 01/01/1965)
Name & Level of Offense
Explanation

Electronic Signature

Please enter your full legal name and today's date below.
By signing this application, you certify that the information contained in this application is true, correct and complete.

Signature	Signature Date
	(ex. 10/25/2022)

On the next page, you will be asked to attach a letter or syllabus for course requirements related to classroom observations.